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Business Insurance Package Quotation FormAIB AUSTRALIA

APPLICANTS DETAILS

Name of Insured in full

*Including Trading Names

& Trusts

Tax Status Registered Business Yes No ABN

Taxable %

Insured’s Phone Email

Postal Address

Post Code

Financier/ Mortgagee Name

Address

Period of Insurance From To

AIB PTY LTD

AFS No: 246282

ABN: 87 009 635 527

Business Insurance Package Quotation Form 100614.pdf

DETAILS OF BUSINESS / PREMISES

Type of Business Or Property owner only

Activities or Processes Involved

If Property Owner Only List of Tenants

Location 1

2

Number of Years In this business At this location 1 At this location 2

AIB INSURANCE – BRISBANE Phone 07 3833 2200 Email [email protected]

AIB INSURANCE – MAROOCHYDOREPhone 07 5409 4600 Email [email protected]

2

DETAILS OF BUSINESS / PREMISES (Cont’d)

Construction of Premises Walls Floors Roof No of Storeys Age of Building

1

2

Are Premises Heritage Listed Situation 1 Yes No Situation 2 Yes No

Location 1 Location 2

Sandwich Foam Panel (EPS- ‐ Expanded Polystyrene) construction greater than 15% of floor area (including Cool Rooms)? Yes No Yes No

If yes % of Building %

Connected to Town Water Yes No Yes No

Is any Commercial Cooking performed? Yes No Yes No

Flammable/toxic/explosive substances used or stored Yes No Yes No

Hazardous processes involved at the premises (welding, cutting, spraying) Yes No Yes No

SECURITY

Is the premises fully enclosed within a modern, secured shopping centre (ie. no external openings to outside centre)? Yes No Yes No

Are there deadlocks on all external doors? Yes No Yes No

Are there bars on all external windows (excluding display windows)? Yes No Yes No

Are there locks on all external windows without bars? Yes No Yes No

Are display windows protected by minimum 11mm plate glass with polycarbonate film or thief resistant laminated glass or security screens, grills or bars? Yes No Yes No

Is there external lighting? Yes No Yes No

Are bollards installed in front of glazing such as glass doors, display windows, roller shutters to prevent ram attacks? Yes No Yes No

Is there a monitored intruder alarm system or local alarm? Yes No Yes No

How is the alarm monitored? - ‐ Local or Back to Base? Yes No Yes No

Is there a taped Closed Circuit TV system installed? Yes No Yes No

Is there a fence/wall, minimum 2 metres high, totally enclosing the premises? Yes No Yes No

3

FIRE PROTECTION

Fire Alarms Yes No Yes No

Fire sprinkler system Yes No Yes No

Thermal detectors Yes No Yes No

Offsite monitoring Yes No Yes No

Fire extinguishers Yes No Yes No

Hoses/Hydrants Yes No Yes No

Fire blanket Yes No Yes No

Smoke detectors Yes No Yes No

None of the above Yes No Yes No

If Cooking Risk please answer below questions

Is the ducting cleaned professionally under contract, at least every 6 months? Yes No

Are filters cleaned under contract at least every 2 weeks? Yes No

Are there wet chemical and/or dry chemical B(E) fire extinguishers and fire blankets in place and serviced every 6 months? Yes No

Is there Deep Frying or Wok Frying at the Premises? Yes No

Does the capacity of single vat or twin vat deep fryers or woks exceed 10 litres? Yes No

If Yes; Total Capacity

Do deep fryers have an automatic cut out switch and/or are they thermostatically controlled and limited to 215°C? Yes No

If the business is licensed to sell liquor, do liquor sales make up more than 50% of turnover? (If the business is not licensed to sell liquor, answer ‘No’) Yes No

Has the business been trading for 3 years or more? Yes No

4

If Woodworking Performed at Premises please answer following questions

Are dust control measures comprising some form of centralised cyclone with flexible ducts to machines & adequate dust collection facilities, or localised dust collection bags for individual machines in place? Yes No

Are floors swept regularly and waste removed on a daily basis? Yes No

Are there fire extinguishers and/or hose reels adequately covering all areas and serviced every 6 months? Yes No

Are there more than 60 litres of Class 3 flammables on the premises at any one time? Yes No

If Yes; How is it stored?

Is all spray painting carried out in an approved spray booth ventilated to an external area? Yes No

Is there a no smoking policy in force on the premises? Yes No

If Panel Beating or related processes carried out please answer following questions

Is all spray painting carried out in a fully enclosed spray booth ventilated to an external area? Yes No

Is there a no smoking policy in force on the premises? Yes No

Are there fire extinguishers and/or hose reels adequately covering all areas and serviced every 6 months? Yes No

Are the baking oven filters cleaned professionally under contract, at least every 6 months? Yes No

Is ducting cleaned professionally under contract, at least every 6 months? Yes No

Are flammable liquids stored within a dedicated section away from the work area? Yes No

Sections Required Location 1 Location 2 Sections

Required Location 1 Location 2

Property Section Yes No Yes No Machinery Breakdown Yes No Yes No

Business Interruption Yes No Yes No

Electronic Equipment Yes No Yes No

Theft Yes No Yes No Tax Audit Yes No Yes No

Money Yes No Yes No Transit Yes No Yes No

Glass Yes No Yes No Employee Dishonesty Yes No Yes No

General Property Yes No Yes No Management Liability Yes No Yes No

Liability Yes No Yes No

5

PROPERTY SECTION

Situation 1 Situation 2

Buildings including landlords fixture’s and fittings

Contents (excluding Money)

Stock in trade including work in progress, customer’s goods

Removal of Debris

Rewriting of records

Is Flood Cover Required Yes No Yes No

Seasonal Increases - ‐ advise periods if different from normal – (Christmas / New Year / Easter)

BUSINESS INTERRUPTION

Cover Type Gross Income Gross Profit

Weekly Benefits Loss of Rent

Indemnity Period $ $

Gross Revenue $ $

Gross Profit $ $

Loss of Rent $ $

Weekly Income $ Weeks $ Weeks

Pay Roll - ‐ do you require payroll to be insured Yes No Yes No

If Yes Provide Break up of % and Weeks $ $

Additional Increased Cost of Working $ $

Claims Preparation Expenses (Accountant Fees) $ $

Accounts Receivable $ $

State any uninsured working expenses

6

BURGLARY

Contents – Including Stock $ $

Contents – Excluding Stock $ $

Stock (excluding Cigarettes, Tobacco and Liquor) $ $

Tobacco, Cigarettes, and Liquor $ $

Rewriting of Documents $ $

Theft without Forcible Entry $ $

Additional Damage to Premises $ $


MONEY

Money In Transit $ $

Money On premises during normal Business Hours $ $

Money in Safe or Strongroom $ $

Money in Personal Custody $ $

Damage to safes and strongrooms $ $


GLASS

Is Cover Required Yes No Yes No

External Glass Yes No Yes No

Internal Glass Yes No Yes No

Amount of Glass Large

Medium

Minor

Large

Medium

Minor

Number of Glass Frontages Single

Double

Multiple

Single

Double

Multiple

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GLASS (Cont’d)

Position

Ground Floor

Above Ground Floor

Inside shopping centre

Ground Floor

Above Ground Floor

Inside shopping centre

Increased cover on advertising signs? $ $

Increased additional benefits? $ $

Increased cover on damaged stock following glass breakage? $ $

MACHINERY BREAKDOWN

Blanket Machinery – Limit Any one Loss $ $

List all items to be Covered: Horsepower/Watt Horsepower/Watt

* If insufficient room please attach separate list

Specified Machinery – please specify item and hp/watt Sum Insured Sum Insured

$

$

$

$

$

$

$

$

Do you wish cover for Deterioration of Refrigerated Goods? Yes No Yes No

Sum Insured $ $

Do your required cover for Business Interruption due to Break-down of Equipment? Yes No Yes No

* If yes specified Machinery Breakdown Policy will need to be written.

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ELECTRONIC EQUIPMENT

Description of Computer Equipment

Year Make Model (inc serial number) Sum Insured Sum Insured

$

$

$

$

$

$

$

$

Description of Electronic Equipment


$

$

$

$

$

$

$

$

Description of all Portable Electronic and Computer Equipment requiring Australia Wide Cover


$

$

$

$

$

$

$

$

Increased Cost of Working $ $

Restoration of Data $ $

GENERAL PROPERTY

Fire and Perils Yes No

Accidental Damage Yes No

Theft with Forcible Entry Yes No

Theft without Forcible Entry Yes No

Unspecified tools of trade and general items (limit per item see policy) (Excluding electronic equipment, mobile phones, photographic & computer equipment)

$

Stock $

9

GENERAL PROPERTY (Cont’d)

Specifies Items ID Number

$

$

$

$

$

$

$

$

LIABILITY

Limit of Liability Required $

Number of staff including working partners/directors

Gross Annual Wages Paid $

Number of locations that you own and/or operate, which are to be covered

Estimated Annual Turnover $

What is you Annual Turnover Breakdown by state %

NSW % ACT % VIC % QLD %

SA % TAS % WA % NT %

Indicate if your Operations Include

Wholesale / Distribution

Manufacture

Processing

Installation

Construction

Design / Formulation

Importing

Exporting

Retail

Property Owner

Services / Repair

Wedding & Heat Processes

On-Site work

Off-Site work

* Please ensure you answer all questions in relation to your Operations

Do you require Property Owners Liability Only Yes No

If Yes, advise:

Location Tenants Occupation Floor Area Gross Rentals

$

$

$

$

* If you require cover other than Property Owners Only please complete below

10

Do you Import or Export any Products Yes No

If Yes, advise:

Imported Goods Which Countries Annual Venue % of Turnover

$

$

$

Goods Exported Which Countries Annual Venue % of Turnover

$

$

$

Do you employ contractors &/or Sub- ‐contractors Yes No

If Yes - ‐ Estimated Annual Payment – Labour Only

Labour & Materials

$

$

Do you ensure contractors &/or subcontractors have their own insurance? Yes No

Do you require insurance to cover your liability for their actions ? Yes No

Advise type of work provided

Do you employ labour hire? Yes No

If Yes Estimated Payment $

Advise type of work provided

Do you perform any work away from your Premises Yes No

If Yes, Activities Details % of Turnover

Does Your Business, or does Your Business intend to transport, handle, use or store dangerous goods in bulk quantities as defined by the Australian Dangerous Goods code? Yes No

If yes please advise full details

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Has Your Business used or handled asbestos at any time? Yes No

If yes please provide full details

Does Your Business carry out any of the following: Use of explosives, bridge construction/ maintenance, demolition activities, building work exceeding 10 metres in height, construction or maintenance work involving chemical works, underground mines, mine sites offshore platforms, aircraft, petrochemical plants, power stations, ships, ports, or supply products to any of these industries?

Yes No


Does Your Business discharge waste or hazardous material into the atmosphere, sewer or elsewhere? Yes No


Has Your Business assumed, or intend to assume liability under any contract, or have You entered into or do You in future intend to enter into any hold harmless agreements? Yes No


Do you have property in Your Physical or Legal Control? Yes No

Estimated value of property in Your Physical of Legal Control $

Type of Goods in your control

Do your Require Testing and/or Delivery of vehicles (driving risk) Yes No Limit any one Vehicle $

Do you perform Welding or Hot Works? Yes No

If yes do you comply with Australian Standard 1674.1- ‐1997 “Safety in welding and allied processes – Fire Precautions” Yes No

Do you Manufacture, Pack or Relabel any products which you sell or distribute? Yes No

If Yes, show % of turnover Manufactured % Pack % Relabel %

Do you design parts of completed components for others? Yes No

Do you manufacture to the designs, formulae, plans and or specifications of others? Yes No

Do you have a quality control manual? Yes No

List main products your business manufactures, packs, relabels

12

TAX AUDIT

Has the Australian Taxation Office served a general Notification to Your Industry that it will be carrying out audits of Your Industry? (If yes Cover is not available) Yes No

Indicate Sum Insured Required (options $10,000/ $20,000 / $30,000 / $40,000 / $50,000) $

Have you or any person who will receive insurance protection under this Section ever been investigated by the Australian Taxation Office? Yes No

If yes, give Date, Details and Outcome of Investigation below Yes No

Number of Directors

List Name of All Directors and Business Entities to be covered by this section

TRANSIT

Applies to goods in a vehicle owned/operated by you only

Number of Vehicles operating

Will goods in Transit include Cigarettes, tobacco or liquor? Yes No

Sum insured per Conveyance $

Estimate annual value of all Shipments $

Description of goods normally carried (Advise if any goods temperature controlled)

** Please note dependant on value and goods – Full Marine Cargo Policy may be required **

13

EMPLOYEE DISHONESTY

Are all employees to be insured for this cover? Yes No

Do all Financial Transactions $1,000 or above require two signatories and/or authorisation by two or more people? Yes No

Have there been any previous losses for this cover (insured or not)? Yes No

Number of employees with responsibility for money, negotiable instruments, stock and/or accounts (other than those listed below)

Number of employees primarily engaged as cashiers, treasurers or paymasters

Number of employees engaged outdoors handling money, negotiable instruments, stock and/or accounts. Employees delivering goods

All other employees not having responsibility for money, negotiable instruments, stock and/or accounts

Limit any one employee or any one event $

MANAGEMENT LIABILITY

Covers Required

Directors and Officers Yes No Limit $

Statutory Liability Yes No Limit $

Employment Practices Yes No Limit $

Company Expenses Yes No Limit $

Total Number of Permanent Staff

Total Number of Casuals, Temporary or other staff

Annual Gross Turnover $

Company Type (eg private company, partnership, sole trader, non profit, public company)

How long have you been in operation

14

MANAGEMENT LIABILITY (Cont’d)

Do you require cover for insolvency? Yes No

Without review or approval from at least one other person, can one individual sign cheques, issue electronic funds transfer, prepare cheque requisitions, handle bank deposits, reconcile bank statements or refund monies? Yes No

Has the company been subject to any formal investigations or audits by any regulatory/governmental body? Yes No

Does the company have Occupational Health & Safety procedures in place? Yes No

Has the company ever sustained any loss through the fraud or dishonesty of any employee or director? Yes No

Has the company had any employment practices issues in the last 5 years? Yes No

Has any director or officer of the company ever had proceedings (civil or criminal) instigated against them alleging misconduct or breaches of the law in their capacity as a director or officer of a company? Yes No

Are any of the directors or employees aware of: Yes No

A) any facts which might give rise to a claim being made against the company or its directors or employees which may be covered under this policy section if it commences. Yes No

B) any facts which would cause a reasonable person to think that the company might suffer a direct financial loss as a result of fraud or dishonesty committed by a staff member Yes No

Does the company conduct business activities in the following countries - ‐ Belarus, Burma (Myanmar), Cote d’Ivoire, Cuba, The Democratic Republic of the Congo, Iran, Iraq, Liberia, North Korea, Sudan, Syria or Zimbabwe?

Yes No

If yes to any of the above questions please provide full details

Please confirm breakdown of turnover by state in %

NSW % ACT % VIC % QLD %

SA % TAS % WA % NT %

PREVIOUS INSURANCE

Current Insurer Policy Number

Number of Claim Free Years Current Excess

Due Date

15

QUESTIONNAIRE

Have You alone, in partnership, jointly with any other party or, if a corporation, jointly with any of its directors:

In the last five (5) years had any insurer decline any claim or proposal, cancel or refuse to renew a policy, or increase the premium or impose special conditions? Yes No

Have any applicants suffered any losses, or had any claims made against them, within the last 5 years whether claimed for or not? Yes No

in the last (10) years been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property? Yes No

in the last five (5) years ever been placed in receivership or liquidation or declared bankrupt? Yes No

Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about, and that you know or should know may affect our decision to insure you? Yes No

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS PLEASE SUPPLY FULL DETAILS, DATE, CIRCUMSTANCES, AMOUNTS, ETC (If insufficient space, please provide additional details on a separate page)

SIGNATURE & DECLARATION

I/We declare that

The information in this application is true and correct and I/We have not withheld any relevant information.

I/We understand that any statement made in this application will be treated as a statement made by all of the people insured.

Signature of Applicant Date

Signature of Applicant Date